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psnet.ahrq.gov/node/61061/psn-pdf
October 28, 2020 - Safer prescribing for hospitalized older adults with an
electronic health records?based prescribing context.
October 28, 2020
Drago K, Sharpe J, De Lima B, et al. Safer prescribing for hospitalized older adults with an electronic health
records?based prescribing context. J Am Geriatrics Soc. 2020;68(9):2123-2127. d…
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psnet.ahrq.gov/node/35572/psn-pdf
February 03, 2011 - The long road to patient safety: a status report on patient
safety systems.
February 3, 2011
Longo DR, Hewett JE, Ge B, et al. The long road to patient safety: a status report on patient safety
systems. JAMA. 2005;294(22):2858-65.
https://psnet.ahrq.gov/issue/long-road-patient-safety-status-report-patient-safety-s…
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psnet.ahrq.gov/node/60635/psn-pdf
January 01, 2021 - Systemic defenses to prevent intravenous medication
errors in hospitals: a systematic review.
July 1, 2020
Kuitunen SK, Niittynen I, Airaksinen M, et al. Systemic Defenses to Prevent Intravenous Medication Errors
in Hospitals. J Patient Saf. 2021;17(8):e1669-e1680. doi:10.1097/pts.0000000000000688.
https://psnet.a…
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psnet.ahrq.gov/node/855097/psn-pdf
November 08, 2023 - Use of the Second Victim Experience and Support Tool
(SVEST) to assess the impact of a departmental peer
support program on anesthesia professionals' second
victim experiences (SVEs) and perceptions of support two
years after implementation.
November 8, 2023
Pelikan M, Finney RE, Jacob A. AANA J. 2023;91(5):…
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psnet.ahrq.gov/node/45829/psn-pdf
June 27, 2018 - Learning from errors: analysis of medication order
voiding in CPOE systems.
June 27, 2018
Kannampallil TG, Abraham J, Solotskaya A, et al. Learning from errors: analysis of medication order
voiding in CPOE systems. J Am Med Inform Assoc. 2017;24(4):762-768. doi:10.1093/jamia/ocw187.
https://psnet.ahrq.gov/issue/le…
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psnet.ahrq.gov/node/48173/psn-pdf
August 28, 2019 - Does learning from mistakes have to be painful? Analysis
of 5 years' experience from the Leeds radiology
educational cases meetings identifies common repetitive
reporting errors and suggests acknowledging and
celebrating excellence (ACE) as a more positive way of
teaching the same lessons.
August 28, 2019
Koo A,…
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psnet.ahrq.gov/node/840170/psn-pdf
November 16, 2022 - Predicting dispensing errors in community pharmacies:
an application of the Systematic Human Error Reduction
and Prediction Approach (SHERPA).
November 16, 2022
Ashour A, Phipps DL, Ashcroft DM. PLoS ONE. 2022;17(1):e0261672.
https://psnet.ahrq.gov/innovation/predicting-dispensing-errors-community-pharmacies-…
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psnet.ahrq.gov/node/34892/psn-pdf
February 03, 2011 - Effects of computerized clinical decision support systems
on practitioner performance and patient outcomes: a
systematic review.
February 3, 2011
Garg AX, Adhikari NKJ, McDonald H, et al. Effects of Computerized Clinical Decision Support Systems on
Practitioner Performance and Patient Outcomes. JAMA. 2005;293(10):…
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psnet.ahrq.gov/node/37478/psn-pdf
February 22, 2011 - Programmable infusion pumps in ICUs: an analysis of
corresponding adverse drug events.
February 22, 2011
Nuckols TK, Bower AG, Paddock SM, et al. Programmable infusion pumps in ICUs: an analysis of
corresponding adverse drug events. J Gen Intern Med. 2008;23 Suppl 1:41-5. doi:10.1007/s11606-007-
0414-y.
https://p…
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psnet.ahrq.gov/node/43474/psn-pdf
August 28, 2017 - Racial and ethnic disparities in patient safety.
August 28, 2017
Okoroh JS, Uribe EF, Weingart SN. Racial and Ethnic Disparities in Patient Safety. J Patient Saf.
2017;13(3):153-161. doi:10.1097/PTS.0000000000000133.
https://psnet.ahrq.gov/issue/racial-and-ethnic-disparities-patient-safety
Prior studies have raise…
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psnet.ahrq.gov/node/74075/psn-pdf
November 17, 2021 - CDC guideline for opioid prescribing associated with
reduced dispensing to certain patients with chronic pain.
November 17, 2021
Townsend T, Cerdá M, Bohnert AS, et al. CDC guideline for opioid prescribing associated with reduced
dispensing to certain patients with chronic pain. Health Aff (Millwood). 2021;40(11):1…
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psnet.ahrq.gov/node/73374/psn-pdf
June 09, 2021 - Effects of pharmacist-conducted medication
reconciliation at discharge on 30-day readmission rates of
patients with chronic obstructive pulmonary disease.
June 9, 2021
Singh D, Fahim G, Ghin HL, et al. Effects of pharmacist-conducted medication reconciliation at discharge
on 30-day readmission rates of patients wi…
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psnet.ahrq.gov/node/46820/psn-pdf
August 20, 2018 - Postsurgical prescriptions for opioid naive patients and
association with overdose and misuse: retrospective
cohort study.
August 20, 2018
Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with
overdose and misuse: retrospective cohort study. BMJ. 2018;360:j5790…
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psnet.ahrq.gov/node/34714/psn-pdf
February 18, 2011 - Relation between malpractice claims and adverse events
due to negligence. Results of the Harvard Medical
Practice Study III.
February 18, 2011
Localio AR, Lawthers AG, Brennan TA, et al. Relation between Malpractice Claims and Adverse Events
Due to Negligence. New England Journal of Medicine. 2010;325(4). doi:10.1…
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psnet.ahrq.gov/node/44960/psn-pdf
February 14, 2017 - Readmissions, observation, and the Hospital
Readmissions Reduction Program.
February 14, 2017
Zuckerman RB, Sheingold SH, Orav J, et al. Readmissions, Observation, and the Hospital Readmissions
Reduction Program. N Engl J Med. 2016;374(16):1543-51. doi:10.1056/NEJMsa1513024.
https://psnet.ahrq.gov/issue/readmissio…
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psnet.ahrq.gov/node/852444/psn-pdf
August 16, 2023 - Comparing rates of adverse events detected in incident
reporting and the Global Trigger Tool: a systematic
review.
August 16, 2023
Hibbert PD, Molloy CJ, Schultz TJ, et al. Comparing rates of adverse events detected in incident reporting
and the Global Trigger Tool: a systematic review. Int J Qual Health Care. 202…
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psnet.ahrq.gov/node/42178/psn-pdf
April 10, 2013 - Outside case review of surgical pathology for referred
patients: the impact on patient care.
April 10, 2013
Swapp RE, Aubry MC, Salomão DR, et al. Outside case review of surgical pathology for referred patients:
the impact on patient care. Arch Pathol Lab Med. 2013;137(2):233-40. doi:10.5858/arpa.2012-0088-OA.
htt…
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psnet.ahrq.gov/node/36586/psn-pdf
July 08, 2008 - House staff team workload and organization effects on
patient outcomes in an academic general internal
medicine inpatient service.
July 8, 2008
Ong M, Bostrom A, Vidyarthi A, et al. House staff team workload and organization effects on patient
outcomes in an academic general internal medicine inpatient service. Ar…
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psnet.ahrq.gov/node/41794/psn-pdf
January 31, 2013 - Safety culture and complications after bariatric surgery.
January 31, 2013
Birkmeyer NJO, Finks JF, Greenberg CK, et al. Safety culture and complications after bariatric surgery.
Ann Surg. 2013;257(2):260-5. doi:10.1097/SLA.0b013e31826c0085.
https://psnet.ahrq.gov/issue/safety-culture-and-complications-after-bariat…
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psnet.ahrq.gov/node/47672/psn-pdf
January 17, 2019 - Adverse events and patient outcomes among hospitalized
children cared for by general pediatricians vs hospitalists.
January 17, 2019
Basco WT. Comparing the Care of Pediatric Hospitalists With That of General Pediatricians. JAMA Netw
Open. 2018;1(8). doi:10.1001/jamanetworkopen.2018.5686.
https://psnet.ahrq.gov/is…